Treating Inpatient Hypertension Likely Does More Harm Than Good: Study

By Megan Brooks

December 29, 2020

NEW YORK (Reuters Health) - Hypertension among adults hospitalized for noncardiac reasons is common but treating it could lead to harm, new research suggests.

"Our findings suggest that hypertension among medical inpatients should be managed conservatively," the researchers say in JAMA Internal Medicine.

"Physicians often feel compelled to act" when there is an abnormal blood pressure reading in the hospital, "but that is not always the best course of action. Most patients with high blood pressure can simply be monitored and their blood pressure will come down in a few hours," Dr. Michael Rothberg with Ohio's Cleveland Clinic told Reuters Health by email.

Elevated blood pressure is common among medical inpatients, but guidelines on how to manage it are lacking and the outcomes associated with intensifying BP treatment in the hospital are poorly studied, Dr. Rothberg and colleagues note in their paper.

To investigate, they took a look back at 22,834 adults admitted to a medicine service at 10 hospitals within the Cleveland Clinic Hospitals health care system in 2017. The average age of the cohort was 66 years and 57% were women; none had cardiovascular diagnoses.

More than three quarters (78%) of the patients had at least one hypertensive BP measurement during their hospital stay but only one-third of these patients had their medication regiment intensified with an intravenous antihypertensive medication or a new class of an oral antihypertensive medication.

In addition, fewer than 10% hypertensive systolic BPs were treated, and less than half (47%) of the systolic blood pressures over 200 mm Hg were treated.

BP elevations tended to be transient. Most elevated systolic BPs dropped at least 20 points by the next measurement, suggesting that simply repeating the BP four hours later may substitute for treatment, the researchers report.

Patients with elevated BP while in the hospital who did have their antihypertensive regimen intensified were at higher cardiovascular risk and had higher BP readings.

"Paradoxically," in a propensity-matched sample controlling for these factors, antihypertensive treatment intensification, which presumably was meant to prevent end-organ damage, was associated with higher rates of acute kidney injury (10.3% with treatment vs 7.9% without; P<0.001) and myocardial injury (1.2% vs 0.6%; P=0.003), the researchers report.

Associated harms with in-hospital antihypertensive medication intensification were similar for both oral and IV treatments and occurred across systolic BP intervals. "We did not find any group of patients whose outcomes were better with treatment," they say.

Most of the patients treated for elevated BP in the hospital were not discharged on the medication and those that were did not have improved BP control in the following year.

Dr. Rothberg said he's not surprised by the results.

"The benefits of treating hypertension usually take months, if not years to manifest themselves, so we didn't expect to see a benefit in just a few hours or days. There is precedent for harm related to lowering blood pressure too fast. In the 1990s, we used to use sublingual nifedipine to treat high blood pressure in the hospital. That stopped when it was shown to cause strokes. Our findings were less worrisome - there was no increase in strokes - but the idea is the same," he told Reuters Health.

"Given the importance of this topic, guidelines would be really helpful," he added. "There are guidelines regarding ambulatory treatment, which have existed for several decades, but there is no guidance for treatment in hospitalized patients. Partly, that is because there hasn't been any evidence until now."

The study had no specific funding and the authors have no relevant disclosures.

SOURCE: JAMA Internal Medicine, online December 28, 2020.